Consent for Medical Ear Piercing

Consent for Medical Ear Piercing
Your Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that fees for ear piercing will not be filed against any insurance. All payment for this service is due at the time of the visit
Initials
I understand the patient's ears will be pierced with pre-sterilized, single use, medical grade plastic or titanium earrings.
Initials
I acknowledge that if the patient has a bleeding disorder, diabetes, high blood pressure, immune disorder, heart condition, allergies, or a skin disorder, then ear piercing may carry a greater risk for my child. I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess.
Initials
Despite all precautions that are taken by Dr. Lee and my proper aftercare treatment, the potential for infection still exists. There is also the potential that one of the following complications may occur as a result of ear piercing: Persistent redness, Swelling, Drainage from piercing, Bleeding from piercing, Embedded clasp, Local wound infection/cellulitis, Bacterial infection of the blood (septicemia), Pressure Sore, Traumatic injury, Abnormal healing of the ear, such as keloid scarring or cauliflower ear. ** Please contact Dr. Lee if the patient experiences any of these symptoms WITHIN THE FIRST 2 MONTHS AFTER PIERCING.
Initials
I read and understand the AFTERCARE INSTRUCTIONS and have received a copy for my reference. Aftercare of piercing is the responsibility of the parent or patient once they leave the office.
Initials
I agree that if at any time it is deemed unsafe for the patient or the medical staff to continue with the procedure, then the procedure will be stopped and potentially rescheduled for another time.
Initials
I have agreed to this ear piercing procedure, and I am fully aware of the potential risks and complications of the procedure. I release Dr. Lee, Complete Care For Kids, PLLC and anyone associated with them from any responsibility once I leave after the procedure.
Initials
I UNDERSTAND THAT I MAY CONTACT DR.LEE REGARDING ANY COMPLICATIONS RELATED TO THE PIERCING IN THE FIRST 2 MONTHS AFTER PIERCING, HOWEVER, AFTER THIS TIME, CARE SHOULD BE SOUGHT WITH THE CLIENT’S REGULAR DOCTOR.
Initials
I have read and understand all the items listed above and I agree to their terms. By signing this document, I certify to Dr. Lee that I am the parent or legal guardian of the minor patient named above, or I am eighteen years or older and able to consent for my own procedures.
Signature
Print Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
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